Sr Government Operations Analyst

Capital Blue Cross•Harrisburg, PA

About The Position

The Senior Operations Business Analyst provides advanced analytical, reporting, and problem‑resolution support across Claims, Customer Service, Enrollment & Billing, and Appeals & Grievances. The role requires deep expertise in Medicare Advantage appeals and grievances, claims processing workflows, data models, and regulatory reporting. This position partners with operational, technical, clinical, and compliance teams to analyze trends, validate data universes, optimize processes, and ensure operational and regulatory performance standards are met. The analyst leverages strong technical acumen, including FACETS, reporting tools, and data extraction techniques, to drive improvements, ensure compliance, and support business decisions. Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market-driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

Requirements

Ability to analyze data, identify trends, determine impacts, and develop solutions for system or process changes affecting claims, appeals & grievances, and regulatory reporting.
Ability to act as a liaison and recommend solutions across departments including Appeals & Grievances, Claims, Customer Service, IT, and external partners.
Strong written and verbal communication skills, able to translate technical reporting, regulatory requirements, and operational data into business‑friendly insights.
Ability to prioritize multiple reporting, analytical, and project tasks with minimal supervision and adapt to changing regulatory or operational priorities.
Ability to create and run queries and extract datasets supporting claims processing, appeals & grievances, and regulatory requirements.
Knowledge of the healthcare industry, Medicare Advantage appeals & grievances regulatory requirements (CMS, Act 68, ERISA, HIPAA, NCQA), and claims processing operations.
Knowledge of data processing concepts, including use of Microsoft Office Suite, Crystal Reporting, and data modeling used for operational and regulatory reporting.
Understanding of corporate reporting requirements, data validation techniques, and CMS universe specifications.
Ability to lead meetings and present findings to management and cross‑functional teams.
3 years of experience working with integrated business systems handling claims, appeals & grievances, membership, and customer service processes.
Experience producing, analyzing, and delivering routine and ad hoc reports, including regulatory datasets (CMS universes) and operational performance dashboards.
Experience navigating peripheral FACETS systems and appeals/claims modules; strong working knowledge of reporting capabilities and data validation.

Nice To Haves

Bachelor’s degree in business administration, health administration, information systems, computer science, or related field preferred.

Responsibilities

Serve as a department project lead for corporate and departmental initiatives, including those involving appeals & grievances reporting, claims operational enhancements, and regulatory changes. Provide written and verbal status updates, identify risks, perform root cause analyses, and recommend process improvements.
Serve as a department project lead for department/corporate projects and/or maintenance activities as assigned. Communicate project team status updates verbally and in writing to all team members. Identify projects risks and contingencies. Conduct root cause analysis and identify process improvement opportunities.
Elicit and document detailed business requirements for system enhancements, data reporting needs, regulatory changes (CMS, State, NCQA), and operational process updates.
Anticipate operational and regulatory problems before they occur, document solution options, work with stakeholders to implement changes, and consider long‑range impacts to appeals, grievances, claims, and administrative workflows.
Proficiently support four (4) or more subject matter areas as a subject matter expert, including Medicare Advantage appeals & grievances processing, claims adjudication, regulatory reporting, data validation, and operational performance analytics.
Mentor less experienced staff, including informal coaching on reporting, appeals workflows, systems navigation, and documentation standards. Support internal and external customers by answering inquiries and producing clear process documentation.
Build strong working relationships across departments (Appeals & Grievances, Claims, IT, Regulatory, Customer Service). Summarize analytical findings, trends, and reporting outcomes in a clear and digestible manner. Facilitate meetings, prepare agendas, minutes, and communicate delays, risks, and impacts.
Perform application testing for system updates, maintenance, and regulatory changes. Execute test scenarios, validate appeals and claims configurations, evaluate defects for operational/regulatory impact, and document findings.
Demonstrate working knowledge of targeted system applications and tasks, including FACETS tables and reporting data structures.